Basic Information
| Provider Information | |||||||||
| NPI: | 1629319058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLY | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSW, LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8028 BROOKE PARK DR | ||||||||
| Address2: | APT 210 | ||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481875100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346264171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2013 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801088381 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.